Contents

1. NEWS and ANALYSIS

A new survey report finds that Global Fund processes are generally more open and inclusive for key populations compared to PEPFAR, though barriers still remain for both. Persistent challenges include access to information and technical assistance, as well as data availability and quality.

2. COMMENTARY

The Global Fund’s Fifth Replenishment is a crucial moment for the future of the three diseases. But even with a fully funded Global Fund, will we be able to “End It for Good”? David Stevenson, former Chair of the Global Fund Strategy Committee, spells out three collective priorities to get the job done.

3. NEWS

There are gaps in malaria services provided to pregnant women in Cameroon, according to the second edition of the Shadow Report published in July 2016 by the community services organization For Impacts in Social Health. Other findings concerning Cameroon’s malaria grant were more encouraging.

4. NEWS

The Secretariat is reviewing the impact of the new Policy on Sustainability, Transition, and Co-Financing on nine components no longer eligible for funding. In GFO #293, we reported that the Board decided not to fund proposed extensions to two grants in Bosnia and Herzegovina. This article provides more information on this decision.

6. NEWS

Additional funding of $109 million for Tanzania’s shortened HIV grant will allow the country to provide antiretroviral treatment to the end of 2017. About half of Tanzanians living with HIV are now receiving ARVs.

7. NEWS

An assessment conducted by the Alliance for Public Health Ukraine reveals that civil society and governments need to collaborate better to ensure that services related to community, rights, and gender continue to be provided as countries transition away from Global Fund support. The assessment concluded that both civil society and governments need technical assistance to make that happen.

8. NEWS

The board approved additional funding of $37 million to allow a shortened HIV grant to Uganda to provide full services through to the end of 2017. The new funds will be used to purchase additional antiretrovirals.

The report is a rapid review of an online survey (99 respondents from 25 African countries); site visits in Nairobi, Kenya and Lilongwe, Malawi; focus group discussions; and key informant interviews in six countries. The majority of survey participants identified themselves as representing men who have sex with men (n=64), lesbian, gay and bisexual people (n=59), and transgender people (n=53), though most respondents said they represented multiple key populations.

The results reveal that engagement levels are significantly higher for Global Fund concept notes than they are for PEPFAR country operational plans (COPs) (Figure 1). Overall, 33% of survey respondents had ever been consulted for a Global Fund concept note compared to just 19% who had participated in a PEPFAR COP. Survey respondents were also more likely to provide input into drafts and budgets for Global Fund concept notes than they were for PEPFAR COPs.

Though participation is reported as higher for the Global Fund than it is for PEPFAR, the Global Fund “engagement cascade” is steeper. This means that key populations who are consulted for Global Fund concept notes are more likely to “drop out” of the process as it progresses towards draft and budget input. Of those ever consulted, only one fifth had provided input into Global Fund concept note budgets compared to nearly one third for PEPFAR COP budgets. This could indicate that while Global Fund processes appear more widely consultative, engagement in PEPFAR processes may be more meaningful, since a greater proportion of those consulted provide input into documents and budgets.

Figure 1: Number of key populations who participated in various stages of consultation

Notably, for both the Global Fund and PEPFAR, respondents were less and less involved as the process evolved. This reinforces the commonly-held view that key populations engagement is often quite superficial.

Information gaps help to explain the low levels of key populations’ engagement for both the Global Fund and PEPFAR, as well as the difference between the two. Only 7% of respondents felt that they understood the Global Fund’s tools and processes well, compared to 4% who said the same for PEPFAR. Both of these figures are exceedingly low. Respondents reported a steep learning curve in engaging with the Global Fund and PEPFAR, including a deluge of acronyms, and new tools and processes to learn. Compounding these difficulties was the fact that this engagement often occurred in the participant’s non-native language. There were also major gaps in budget knowledge identified.

Access to information includes knowing how and where to ask for help. Aidspan has previously reported that representatives of key populations are less likely than other civil society members to know they can request technical assistance (TA) from the Global Fund’s Community, Rights and Gender (CRG) department. This knowledge barrier directly translates into limited access to support. AMSHeR’s survey revealed that just 3% (n=3) of respondents reported that they received Global Fund CRG technical assistance (Figure 2). An overwhelming proportion (47%) did not even know that GRG TA was available. This is a slight improvement over the results of another survey conducted by the Eastern Africa National Network of AIDS Service Organizations (EANNASO) six months earlier, which found that 71% of key populations were unaware of the CRG technical assistance program. This could indicate that key populations knowledge of CRG TA is improving over time.

The survey report identifies the availability and quality of data on key populations in Africa as another possible explanation for the limited engagement of these communities in PEPFAR and the Global Fund. According to respondents, the number of people who make up key population communities is grossly underestimated, which has significant implications on how loudly their voices are heard in negotiating spaces. One respondent from Kenya raised questions about how the country’s size estimate of 10,000 men who have sex with men was reached. “We had disputes over how the data was collected. We questioned where they got their information,” says Peter Njane, Executive Director of Ishtar-MSM.

In support of Njane’s view, a systematic review presented at the 21st International AIDS Conference confirmed that key populations themselves are seldom meaningfully involved in their own size estimation studies. Out of the 71 key population size estimations reviewed, just 12 had evidence of key population engagement during study design.

Despite persistent barriers faced by key populations when engaging in both Global Fund and PEPFAR processes, respondents insist that progress must not be discounted. “We are getting there, compared to two years back,” one participant affirms. Most expressed cautious optimism, saying they would continue to engage, while asserting that much remains to be done to deliver on the promises made by the Global Fund, PEPFAR, and other global financing institutions with respect to engagement.

“I was formerly part of the team at the Global Fund who developed the new funding model,” said Meg Davis, lead author of the survey report. “The research confirmed both my best hopes and worst fears,” she continued. “We found that key populations have seized the opening to engage in country after country, but that many were out-gamed and shut out when the time came to actually dole out the funds. If national HIV programs don't do better at directly funding key populations-led work, there will be no ‘end of AIDS’– end of story.”